Abstinence-only sex education has been a detriment to our nation's sexual health that we seemed to be leaving behind. The Obama administration's decision last year to cut funding for abstinence-only programs in favor of scientifically reliable programs marked a new opportunity to provide young people with the tools that they needed. As an organization that promotes sexual learning throughout the lifespan, the NSRC was excited by the prospect of national sex education that could provide our nation's youth with tools for a sexually healthy present and future.

That's why we were alarmed by a recent Washington Post article by Rob Stein about a study of an abstinence only program that was more effective than comprehensive sex education. The study showed that the abstinence-only program had slightly higher levels of students postponing sex during the research period, but the article framed the results as a major turning point for abstinence-only sex education, one that could potentially alter the future landscape of sex education by continuing abstinence-only sex education.

However, the reality of the study in question is that it does not support most abstinence-only sex education, and particularly does not show that the abstinence-only-until-marriage sex education that was promoted by the Bush administration is effective. The article acknowledges, albeit after allowing conservative voices to have their say, that various critics have noted that the program under review "did not take a moralistic tone, as many abstinence programs do. Most notably, the sessions encouraged children to delay sex until they are ready, not necessarily until married; did not portray sex outside marriage as never appropriate; and did not disparage condoms". James Wagoner of Advocates for Youth outlines how, for these reasons and others, this program does not represent most abstinence-only programs and would not have met Bush-era requirements for federal funding. While conservative organizations might still be trying to portray this research as validating abstinence-only sex education, Robin Marty at RH Reality Check points out that the program in this study, by teaching young people both to wait for sex until they are ready and by providing them safe-sex information for when they are, is more in line with comprehensive sex education programs and the research that has shown their effectiveness.

In addition to downplaying the aspects of the study that might undermine its support for abstinence-only programs, the article almost entirely neglected the abundance of research that puts the validity of abstinence-only sex education into question. A 2008 issue of our journal Sexuality Research and Social Policy highlighted a number of the areas in which abstinence-only sex education has failed, from an inability to delay teen sex in most cases, to creating a public health risk through false information about condoms, and generally denying the human rights of teens through denying their access to health information. Evidence against abstinence-only sex education is so extensive that in late 2007 a group of leading sexuality researchers sent a letter to House Speaker Nancy Pelosi urging Congress to end funding for these ineffective programs.

As an organization that supports sexual health through life-long learning, we can only voice our disappointment and dismay at this article. While delaying sexuality until one is ready is a healthy decision, attempting to deny youth their sexuality through lying and misinformation only causes greater problems. As James Wagoner points out in his post, abstinence-only programs do not delay teen sexuality forever, but merely postpones the intiation of youth sexuality into the late teens. If 70% percent of youth are still sexually active by the time they are 19, what can we expect to happen to them when they've been denied access to accurate sexual health information? Is slightly delaying the onset of youth sexuality a better outcome than providing youth with accurate health information to protect themselves and their peers? This question is even more pressing when the vast majority of research shows that abstinence-only sex education programs don't even delay teen sexuality as well as programs that provide youth with accurate health information.

Here at NSRC, we support the continued efforts to provide people of all ages with the information they need to live a sexually healthy and happy life. While the current political climate is one in which deception and misinformation have become standard tools of the trade, it's our stance that through providing people with real knowledge, we can make a positive impact on their lives and ours.

Jack Mohr is the communications intern at the National Sexuality Resource Center. He is also a student in the Sexuality Studies MA program at San Francisco State University. For his graduate project, he organized The Bisexual Art Project, an art show that explored the different ways individuals understand and engage with their bisexuality.

To test the so-called sensitivity spray, scientists gave 24 healthy men the cuddle drug spray while 24 other men got a placebo. The scientists worked with researchers at the Babraham Institute in Cambridge, and their findings appear in the Journal of Neuroscience.

After their noses got squirted with spray, the men looked at "emotionally loaded" photos like a crying child or a man in mourning. Afterward, they were asked to discuss how much empathy they felt with the people in the photos. The men who got the sensitivity spray displayed much more emotional empathy than the men who got the placebo, according to Dr. Rene Hurlemann of Bonn, Germany. The doctor said the men who had gotten the oxytocin spray attained "the levels of sensitivity usually found in females."

Hurlemann said the study "shows for the first time that the emotional-projecting ability of oxytocin can be created." The spray could one day prove effective in treating schizophrenics, who often are unable to connect with others and who tend to lack social skills.

SYDNEY — Tobacco companies would be forced to use plain, logo-free packaging on their cigarettes in a bid to make them less attractive to smokers under legislation introduced Thursday by Australia's government, which dubbed the move a world-first.

The rules, which would take effect July 1, 2012, would ban tobacco companies from including logos, promotional text or colorful images on cigarette packages. Graphic government health warnings would be prominently displayed instead, with the brand name relegated to tiny, generic font at the bottom.

"The new branding for cigarettes will be the most hard-line regime in the world and cigarette companies will hate it," Prime Minister Kevin Rudd said.

The government also announced it would increase the cigarette tax by 25 percent, driving up the price of a pack of 30 cigarettes by about 2 Australian dollars and 16 cents ($2). The tax was to go into effect at midnight Thursday.

Tobacco companies immediately blasted the packaging crackdown, and vowed to fight it in court.

Retailers said the tax hike would hurt their businesses and bolster the cigarette black market.

"It's a lazy policy response being pushed by some health advocates," Mick Daly, National Chairman of Australian supermarket chain IGA, said in a statement. "That amounts to a direct attack on approximately 16 percent of Australians who have made legal and legitimate lifestyle choices."

Tim Wilson, director of intellectual property and free trade at Australia's Institute of Public Affairs, said taxpayers could end up paying around AU$3 billion a year in compensation to tobacco companies.

KFC's move to team up with the Susan G. Komen for the Cure to fight breast cancer has some folks clucking in outrage. The fried chicken chain, purveyor of a food that may contribute to obesity, partnering with the world’s largest breast cancer organization?

"A lot of folks are questioning just how appropriate it is for a fast-food chain that sells, well, not exactly the most healthful food, to partner with a group known globally for helping save women's lives," wrote Erin Allday in the San Francisco Chronicle.

The chicken chain is changing the traditional red color of its buckets to pink until the end of May and donating 50 cents for every bucket sold in what’s being billed as the "Buckets for the Cure" campaign. So far, about $1.9 million has been raised, and KFC has set a goal of more than $8 million, according to the Buckets for the Cure Web site.

It’s not, as the San Francisco Chronicle points out, the first time that "junk food" purveyors and organizations that promote wellness have collaborated. Pepsi is financing a program in obesity studies at Yale, McDonald’s is a long-term sponsor of the Olympics, and a program to promote heart and lung health that partnered with Coke earlier this year drew criticism, according to the San Francisco Chronicle.

With the KFC and Susan G. Komen collaboration, as blogger Yoni Freedhoff of Weighty Matters points out, consumers who buy the buckets of chicken are likely to also buy fries, gravy and soda, too. "So, in effect, Susan G. Komen for the Cure is helping to sell deep-fried fast food and, in so doing, help fuel unhealthy diet and obesity across America, an odd plan given that diet and obesity certainly impact on both the incidence and recurrence of breast cancer," Freedhoff wrote. And suggested that a possible alternative would have been for KFC to just hand over a check for breast cancer research to Susan G. Komen for the Cure.

Bruce Feiler's twin daughters, Eden and Tybee, were 3 when he was diagnosed with a rare form of bone cancer in 2008. Just days afterward, the best-selling Brooklyn author came up with the idea of asking six friends to look out for his daughters should he not survive. Feiler's moving new book, "The Council of Dads," tells their story.

How did the Council of Dads come about?

It was a reaction to a fear about what my daughters' lives might be like without me. The first thing I imagined was all the things I would miss ... all the questions they would have. "What would Daddy think about this?" "What would Daddy say about that?"

Where did the idea spring from?

I awoke from a half sleep, and there was ... this letter forming in my head to my closest friends asking them to be there to answer my daughters' questions. I said out loud, "I will call this group of men the Council of Dads." As soon as I said those words, it seemed like they lived in the room.

How did you choose the members?

I was trying to fill the dad space. My wife, Linda, and I agreed that we should pick people who embodied all sides of me, each phase of my life. There is a travel dad. A make-your-dreams-happen dad. A values dad. A playful dad. A thinking dad. A nature dad. Now I kind of think of it as a team of godparents updated for a modern age.

How did it affect your friendships with the men?

The first time I read the letter to a friend I'd chosen, he's crying. I'm crying. He said yes, and I was taken aback. I hadn't realized this was a request you could turn down. In the end, they weren't family, they weren't just friends anymore. We − my wife and I and the girls − just had this whole new relationship in our lives.

It also changed your life?

The Council of Dads turns out to be less about parenting and more about friendship. We all think there's a divide between family and friends. And when you have children, you can be so busy you think you don't have time for friends. This built a bridge between our closest friends and our closest treasures, our children.

How did the council work?

They never came together. They would come to see me in the hospital. But what started happening is that they would always build in time to visit with the girls. These aren't just Daddy friends anymore. They are friends of theirs. The girls have nicknames for all of them.

You're cancer-free. What is the status of the Council of Dads?

There is something incredibly powerful about telling your closest friends what they mean to you. It's like we're friend-married now. It's like "till death do us part."

The council is an idea that is catching on.

The word has gotten around, and others are forming their own councils. I'm seeing divorced women do councils of dads because they want the male voice in their children's lives. Women have councils of moms. I'm involved with a special program with the military to form councils of moms and councils of dads.

What do your daughters know about the council?

They know they have a Council of Dads. They don't know that the shadow of mortality hangs over the thing. I want to be honest with them, but not too honest.

A young farmer who suffered a gunshot wound to the face has received the world's first full facial transplant at a hospital in Spain.

The 24-hour operation, carried out by a 30-member surgical team at Vall d'Hebron Hospital in Barcelona, marks the first time an entire face — including the skin, muscles, teeth, lips, cheekbones and jaw — has been transplanted and reconstructed, using tissue from a brain-dead donor, the Times of London reported.

The transplant recipient, identified only as a man in his 30s, lost his nose, jaw, and other parts of his face when he accidentally shot himself in 2005. He was left with nothing but a hole between his mouth and where his nose should have been, and had been unable to eat, speak or breathe normally for the last five years.

The surgery was carried out March 30.

Dr. Joan Pere Barret, the lead surgeon, said that the procedure was a complete success and that the patient was recovering well in the hospital with no sign of tissue rejection or infection.

"It is a full-face transplant, restoring all the bones and no grafts," Barret told the Times of London. "He has the face of a complete new human being. Relatives say that he looks in some areas like he did before the accident, but he doesn't look like the donor at all. He's changed completely."

Barret said the man asked to see his face seven days after the surgery.

"He was very pleased and satisfied," the surgeon said. "From our point of view, he looks fantastic. He is the best facial transplant ever."

The procedure involved removing the entire facial skin and muscles, nose, lips, palate, teeth, cheekbones and the jawbone from the donor while preserving the blood supply.

The patient's arteries and veins were then isolated and the donor's face checked to ensure that there was a complete flow of blood.

Then bones, nerves and muscles were transplanted and connected to his own blood vessels, nerves and skin. Metal plates were used to support the structure of the new face, which included reconstructing the roof of the mouth.

The patient is able to walk and sits in a chair to watch TV. He is expected to start "talking and eating, and also smiling and laughing" within a few weeks' time, Barret said. "He couldn't talk at all before the surgery, but our plan is that with steroids and other drugs we are considering to allow him to start swallowing next week."

The patient underwent psychiatric tests before the operation to determine if he would be able to confront having a totally new face, the hospital said.

He is likely to remain in hospital for at least two months and will be closely monitored for four months after that. But he should eventually be left with a normal appearance, without scars or distortions in the skin.

Before the transplant, the young man had been operated on nine times, but still had severe difficulty breathing, swallowing and speaking. He had to breathe and be fed through tubes, the hospital said.

Although at least 10 facial transplants have been performed in France, the U.S., China and Spain, all have involved only part of the face. This is said to be the first time a full-face procedure has been carried out.

"The alarming thing is that it's occurring in this region, it's affecting healthy people, and geographically it's been expanding," study co-author Edmond Byrnes, a graduate student at Duke University, told the magazine.

Experts are baffled as to how the fungus reached North American and how it could survive in a colder climate.

Even more worrisome for health experts are reports that the victims had relatively healthy immune systems, according to National Geographic. Twenty one known cases have been recorded in humans, and six have been fatal.

A 1999 outbreak of a similar strain of the fungus in British Columbia, Canada, had a much lower mortality rate, killing 19 out of 218 recorded victims.

There is currently no vaccine for the fungus strain, which causes an infection which may not display symptoms -- including a bad cough and shortness of breath - until months after exposure.

"The enhanced virulence of isolates from the outbreak region, when compared with those from other regions, suggests that the genotypes circulating in the Pacific North West are inherently increased in their predilection to cause disease in mammalian hosts," the study authors wrote in the April 22 issue of the scientific journal, PLOS Pathogens.

Botox may kill your wrinkles, but it could also cost you your social life, a new study suggests.

Research from the University of Wisconsin-Madison published in the journal Psychological Science found that the wrinkle-smoothing treatment not only stops frown lines, it also increases the amount of time it takes to react to emotional events - potentially leading to socially awkward encounters.

The study monitored the speed at which 40 volunteers processed written statements before and after receiving Botox injections around the mouth. Scenarios in the statements included such negative events as being ignored on their birthday or being interrupted by a telemarketer at dinner.

The subjects took "significantly longer" to grasp and react to the negative concepts after the injections deadened their frown muscles, according to the study.

“Blocking facial expression diminishes the experience of emotion,” lead researcher David Havastold Britain's Sunday Times. “Our faces are normally alive with activity, which contributes to our understanding of each other, and there is a strong link between our facial expression and our ability to comprehend the meaning of language.

“If people seem slow in reacting to what they are being told, it is likely to be interpreted as a lack of sympathy or interest.”

Subjects reacted to positive news at normal speed, but that could be because this study focused on frown muscles and not smile areas like crow's feet, Havas said.

Jenkins, co-director of the neurosurgery Spine Program at Mount Sinai, sums up his job in three words: “I fix spines.” He performs spinal reconstructions, decompressions, stabilizations and deformity correction for the whole spectrum of spinal disorders.

WHO’S AT RISK

Spinal metastases are cancers that originate elsewhere and spread to the spine. “Everyone who has cancer is at risk,” says Jenkins. “Ten percent of patients with cancer eventually develop spread to the spine.” With 1.5 million Americans diagnosed with cancer each year, that means 150,000 of them may also develop a spinal tumor.

“Lung, breast and prostate cancers are all tumors that are common, and therefore are common causes of spread to the spine,” says Jenkins. “Any cancer can spread to other parts of the body.” tumors that originate in the spine have a different prognosis, and doctors often try to remove the whole cancer in hopes of a cure. “Whereas metastatic cancers tend to be incurable but significantly manageable,” says Jenkins. “the question is, ‘How can we manage [patients’] disease to give them the longest quality of life?’ ”

As for risk factors: “Things that predispose you to having a cancer in the first place — like smoking, hepatitis, exposure to carcinogens, infection and environmental factors — also predispose you to having a metastatic tumor,” says Jenkins. Age can also be a factor, because the longer you live, the more likely you are to have some kind of cancer.

SIGNS AND SYMPTOMS

The major warning signs of spinal metastases are pain, weakness and instability. “Any new neurological symptoms or new pain, especially in a cancer survivor, should be evaluated by a clinician to make sure it’s not a spread to the spine,” says Jenkins. Commonly, pain will occur when walking or bearing weight. Other symptoms include difficulty controlling how well you go to the bathroom, and pain that goes down the legs, back or arms.

Although spinal metastases go undiagnosed in some people, most doctors are vigilant about watching cancer survivors for new symptoms. “If patients follow up with their clinicians and their clinicians do a thorough examination, usually they get taken care of pretty quickly,” says Jenkins.

TRADITIONAL TREATMENT

Cancers that have spread to the spine are usually past the point of curing. However, that does not mean treatment is unnecessary. “The big problem is that spinal metastases will grow without any resistance and erode the spinal bones or compress the surrounding structures,” says Jenkins. “That can cause pain, weakness and paraplegia.”

Near-death experiences like seeing a bright light at the end of a tunnel may occur because of high carbon dioxide levels in the blood, according to a new study reported by BBC News.

Up to a quarter of cardiac arrest patients have reported mysterious experiences, which might include an "out of body" feeling or the sensation of looking down from the ceiling to the room below.

In the past, it was theorized that the phenomenon could be due to drugs or religious beliefs. But when Slovenian researchers at the University of Maribor examined 52 cardiac arrest patients, they discovered that levels of the colorless chemical compound were significantly higher in the 11 patients who said they had had a near-death experience. The study appeared in the journal Critical Care.

"It is potentially another piece of the puzzle, although much more work is needed," report author Zalika Klemenc-Ketis told BBC News. "Near-death experiences make us address our understanding of human consciousness so the more we know the better."

Some of the cardiac arrest patients who report a near-death experience - the figure ranges from one in 10 to nearly 25% - have said they felt overwhelmingly peaceful and tranquil, while others said they could see a mystical entity or bright light.

It’s known that inhaling carbon dioxide can bring on a hallucinatory experience not dissimilar to the type of feeling reported by the patients. Still a mystery is whether the higher levels of carbon dioxide among the group of 11 patients were due to the cardiac arrest or pre-existing.

It had been theorized that anoxia, a condition in which oxygen-deprived cells die - might be the reason why near-death experiences happen, but this was not of statistical significance among the patients in this study.

Dr. Pim van Lommel, a cardiologist who has studied near-death experiences, called the study "interesting," according to BBC News.

"But they have not found a cause - merely an association," he said. "I think this is something that will remain one of the great mysteries of mankind. The tools scientists have are simply not sufficient to explain it."

The U.S. Food and Drug Administration said on Thursday it was reviewing the safety of triclosan, a widely used antibacterial agent found in soap, toothpaste and a range of other consumer products.

The agency stressed there are no grounds to recommend any changes in the use of triclosan but said some recent studies merited a closer look.

One member of Congress, Massachusetts Democrat Edward Markey, called for strict limits.

"Despite the fact that this chemical is found in everything from soaps to socks, there are many troubling questions about triclosan's effectiveness and potentially harmful effects, especially for children," Markey said in a statement.

"I call upon the federal government to ban the use of triclosan in consumer soaps and hand-washes, products intended for use by children, and products intended to come into contact with food. In addition, I will soon introduce legislation to speed up the government's efforts to evaluate and regulate other substances that may pose similar public health concerns."

The FDA noted that there was no evidence that triclosan could be harmful to people but noted that an animal study showed the chemical may alter hormone regulation and several other lab studies showed that bacteria may be able to evolve resistance to triclosan in a way that can help them also resist antibiotics.

Other studies have shown no evidence this has actually occurred in nature, however. Nonetheless, the Environmental Protection Agency has said it will speed up its planned review of triclosan.

"FDA does not have sufficient safety evidence to recommend changing consumer use of products that contain triclosan at this time," the agency said in a statement posted here

The Soap and Detergent Association has repeatedly defended the safety of triclosan, which has been in use for about 30 years.

"The public deserves to know that these so-called antibacterial products are no more effective in preventing infections than regular soap and water and may, in fact, be dangerous to their health in the long run."

Many experts agree that soap containing triclosan does little or nothing extra to remove bacteria that using soap without the ingredient, as washing the hands physically removes the excess bacteria.

A few classes are coed, but male-only gatherings tend to be more popular and have become a mini-phenomenon in the gay community, with studios in Boston, San Francisco, Los Angeles and Salt Lake City. A studioless group in Chicago practices in the apartment of a nude yoga enthusiast.

Fans say the nudity aids in deepening their yoga practice while building a close — and emphatically nonsexual — community. "A lot of people, especially living in New York, don't get the opportunity to connect with people in an intimate way," said Aaron Star, who started the naked yoga movement.

And while participants do occasionally report a frisson of excitement, Star and the practice's aficionados make one thing clear: This is about physical fitness.

"This is about yoga and appreciating your body," said John Cottrell, 40, who teaches naked yoga classes in Salt Lake City twice a month. He calls them a safe, nonthreatening space "to help men especially look at themselves in a different way."

"It's just fun. It's a great workout," he says.

Star began the practice to appeal to a primarily gay male audience and achieved fame in the yoga world with his DVD series "Hot Nude Yoga," which allows aspiring yogis to practice in the privacy of their homes.

Hot, yes — in temperature, for starters.

Awkward? That, too.

At a recent small class taught by Jeffrey Duval in New York, an undeniable sexual charge hung in the room, making the exercise at times painfully weird and embarrassing. Many nude yoga classes revolve around partnering positions, a series of postures that put two men within striking distance of the other's privates.

Not all serious yogis think the practice makes sense.

"I don't see the point," said Mary Dillion, who teaches clothed yoga in Manhattan. "I have a yoga practice that I like and I can be naked in my home. I don't need to do naked yoga."

And Joshua Stein, editor-at-large for OUT Magazine, who attended a class in 2008, says the quality of the yoga was diminished by the heightened sensuality.

"It's almost if the yoga is something between an afterthought and an excuse," said Stein, who is heterosexual. "It gives you this gray area where you can be intimate physically, but not so aggressively intimate as in a bath house or in a bar."

He describes being asked to do a child's pose — a kneeling pose with arms stretched forward on the ground — while a partner draped himself on his back. "It's not something you really need a partner to do," he said.

Star acknowledges that partner work is a popular feature of Hot Nude Yoga that "generates a certain amount of heat" and keeps his client list high. Still, practitioners say they constantly combat the notion that their classes are orgies veiled as exercise.

At Nude Yoga NYC in Manhattan, nude yoga isn't such a boys club. Instructor Isis Phoenix, 29, said her coed nude yoga studio attracts "a well-rounded population of ages, genders and sexual orientations." The men usually outnumber women two-to-one, however.

Phoenix sees nudity as an extra pull for men, who often need an incentive to practice yoga. Still, she nixed the idea that nudity created a sexual element, but one of comfort.

"Men more often fall into a general greater ease with their bodies than women do," she said.

But the trend seems to appeal mostly to gay men. David Flewelling teaches Mudraforce Yoga at a home studio in Montreal, Canada. As at Star and Cottrell's studios, the majority of attendees at Mudraforce are gay.

Flewelling said sex is never part of the experience. Nude yoga, while extremely sensual, is not sexual, he said.

"There's something fantastic about exercising without clothes," he said. "You're free of the restrictions that clothes put on and it puts everyone on even keel."

Even teachers of naked yoga, while railing against the suggestion that the class is tantamount for foreplay, can send mixed signals. Duval, the New York nude yoga instructor, acknowledged he attended his first class because he thought it was about sex. But his experience surpassed all his expectations.

"You're shedding away your clothes, but you're also shedding away insecurities and fear," he said. "I can't think of a more perfect way to practice."

Many successful dieters get stuck near the end of their weight loss journey, but nutritionists and trainers say there are ways to move past the frustration:

Reconsider your weight goal. You may have set your target too low. Think more about health and fitness level, as well as body fat percentage.

Shake up your fitness routine. When your body gets too used to one type of exercise, you don't need to burn as many calories to get through a workout. Add 10 or 15 minutes on an exercise machine, alternate periods of high and low intensity, walk at a brisker pace — or try something new altogether.

Don't starve yourself. Your metabolism will slow, which could lead to future weight gain. To feel fuller, add healthy proteins to meals and snacks, such as a thin spread of peanut butter on whole-wheat bread or sliced turkey on a salad.

Look for little diet trims. Some examples: Eat one slice of bread on a sandwich instead of two, order a child-size scoop of ice cream rather than a small, use less oil when you cook and switch to lower-fat cheeses.

Beware high-calorie drinks. Many dieters sabotage their efforts with coffee drinks, alcoholic beverages and smoothies full of fat, calories and sugar. Drink plenty of water and get specialty drinks with non-fat milk and no syrup added.

Measure yourself differently. Instead of obsessing over numbers on the scale, look at inches lost from your waist and hips and drops in clothing sizes.

As a parent, you want Amber Madison to explain sexting to you. Not the definition — you're clear as a bell on that. You want her to explain why. Why kids do it and what you can do to stop it and what, by the way, has the world come to?

Madison, 26, is a Tufts University-educated sex expert. She wrote a book called "Hooking Up: A Girl's All-Out Guide to Sex and Sexuality" (Prometheus), and she tours the U.S. talking to teens about sex. Now she's out to educate parents with her new book, "Talking Sex With your Kids" (Adams Media).

One out of every three students has had sex by freshman year of high school, according to a 2007 Youth Risk Behavior Survey. By senior year, that rises to two out of three. Kids are having sex. Madison isn't trying to change that — or help parents change it. She's out to make kids better at it — better at knowing when they're ready, better at protecting themselves from sexually transmitted diseases and unplanned pregnancies, better at choosing worthy partners and, of course, better at talking about it.

We chatted with Madison recently about a few of the book's key passages.

The decision to have sex should not be presented as synonymous with the feeling of being in love or the label of having a boyfriend or girlfriend.

"Too often parents go to these concrete labels of when sex is OK, but the labels are debatable," Madison says. "A 13-year-old might think she's in love. But you don't want your 13-year-old daughter thinking ‘I'm in love, so sex is OK.'

When is sex OK? When you feel emotionally ready, when you feel ready to handle any possible consequences, when you feel supported and know the other person will be there for you during any consequences, when you don't feel pressured into it, when you're really doing it for you. A teenager can take that information and make decisions based on those criteria instead of some arbitrary labels of boyfriend, girlfriend, love."

Of all the things that girls are told about sex, very few are told that they're supposed to like it.

"Teaching girls to enjoy sex will help them feel empowered to make safer choices. Girls are told so much, ‘You'll feel used. You'll totally regret it,' so when they're entering into a situation where they don't feel completely comfortable, they figure, ‘Well, that's what sex is like. It's not a problem with this guy or this relationship.' Sex should be amazing. It should feel really good and be something you really want to do. So if you're in a situation where it doesn't feel like something you really want to do or you're not quite ready, you listen to that. Sex should never feel bad."

Young men aren't dogs sitting under the table waiting for whatever scraps get thrown in their general direction.

"So many parents hear ‘Talk to your kids about sex,' and that gets flipped around to ‘Talk to your daughters about sex,' but young men need to hear just as much and no one is talking to them. No one is telling guys sex is a big deal and it should be a big deal. They shouldn't feel automatically ready. All the things we tell young women about being ready to have sex need to be told to young men too."

Beneath (it all) is a confused, vulnerable kid. A kid who still thinks sex is a big deal.

"Parents see the way kids are talking at bar mitzvahs, the tight yoga pants, sexting and they take it to mean, ‘Oh my god, kids are having sex.' Teens act sexual because that's what they see on TV. That's how adults act. It gets them attention.

Don't assume kids are out looking for sex just because they talk or act in a sexual manner. Teens are always very quick to joke about sex, but that doesn't mean they really feel OK about it."hstevens@tribune.com

Hi Cecilia. This is a great question, as skipping breakfast has been linked to childhood obesity, diminished health and nutrition status and compromised school performance. Breakfast quality is just as important as consuming breakfast regularly. Research shows that eating a lower glycemic index breakfast (one that raises blood sugar levels more gradually), can improve school performance and may also help with blood sugar control throughout the day. Whole grains are generally lower glycemic, as they are higher in fiber and less processed. In addition, adding lean protein or healthy fat to a meal decreases the glycemic index, so there are lots of healthy options beyond cereal, oatmeal and eggs. Here are a few suggestions:

2. Fruit smoothie: Combine fresh or frozen fruit with one-half cup low-fat milk and one-half cup yogurt for a creamy and healthy breakfast smoothie. You can also add a little juice (no more than 4 ounces) to increase sweetness.

3. Yogurt parfait: Combine low-fat yogurt (plain is best but vanilla is good, too; it is lower in sugar than fruit-flavored options), one-half cup fresh fruit, and 2 tablespoons of chopped or whole nuts.

4. Cottage cheese and fruit: Low fat cottage cheese is an excellent source of protein. Add your own fruit (pineapple and peaches work well) rather than buying products pre-packaged with fruit, which tend to have added sugar.

5. Grilled cheese: If you are looking for a hot breakfast option, you might want to try a grilled cheese sandwich on whole grain bread (or white wheat) for a healthy dose of calcium, protein and fiber. Add a side of fruit to boost nutrients even further.

Imagine being charged with a crime, but an imaginary friend takes the rap for you.

That is essentially what happened when Pfizer, the world's largest pharmaceutical company, was caught illegally marketing Bextra, a painkiller that was taken off the market in 2005 because of safety concerns.

When the criminal case was announced last fall, federal officials touted their prosecution as a model for tough, effective enforcement. "It sends a clear message" to the pharmaceutical industry, said Kevin Perkins, assistant director of the FBI's Criminal Investigative Division.

But beyond the fanfare, a CNN Special Investigation found another story, one that officials downplayed when they declared victory. It's a story about the power major pharmaceutical companies have even when they break the laws intended to protect patients.

Big plans for Bextra

The story begins in 2001, when Bextra was about to hit the market. The drug was part of a revolutionary class of painkillers known as Cox-2 inhibitors that were supposed to be safer than generic drugs, but at 20 times the price of ibuprofen.

Pfizer and its marketing partner, Pharmacia, planned to sell Bextra as a treatment for acute pain, the kind you have after surgery.

But in November 2001, the U.S. Food and Drug Administration said Bextra was not safe for patients at high risk of heart attacks and strokes.

The FDA approved Bextra only for arthritis and menstrual cramps. It rejected the drug in higher doses for acute, surgical pain.

Promoting drugs for unapproved uses can put patients at risk by circumventing the FDA's judgment over which products are safe and effective. For that reason, "off-label" promotion is against the law.

If we prosecute Pfizer ... a lot of the people who work for the company who haven't engaged in criminal activity would get hurt.--Mike Loucks, federal prosecutor

But with billions of dollars of profits at stake, marketing and sales managers across the country nonetheless targeted anesthesiologists, foot surgeons, orthopedic surgeons and oral surgeons. "Anyone that use[d] a scalpel for a living," one district manager advised in a document prosecutors would later cite.

A manager in Florida e-mailed his sales reps a scripted sales pitch that claimed -- falsely -- that the FDA had given Bextra "a clean bill of health" all the way up to a 40 mg dose, which is twice what the FDA actually said was safe.

Doctors as pitchmen

Internal company documents show that Pfizer and Pharmacia (which Pfizer later bought) used a multimillion-dollar medical education budget to pay hundreds of doctors as speakers and consultants to tout Bextra.

Pfizer said in court that "the company's intent was pure": to foster a legal exchange of scientific information among doctors.

But an internal marketing plan called for training physicians "to serve as public relations spokespeople."

According to Lewis Morris, chief counsel to the inspector general at the U.S. Department of Health and Human Services, "They pushed the envelope so far past any reasonable interpretation of the law that it's simply outrageous."

Pfizer's chief compliance officer, Doug Lanker, said that "in a large sales force, successful sales techniques spread quickly," but that top Pfizer executives were not aware of the "significant mis-promotion issue with Bextra" until federal prosecutors began to show them the evidence.

By April 2005, when Bextra was taken off the market, more than half of its $1.7 billion in profits had come from prescriptions written for uses the FDA had rejected.

Too big to nail

But when it came to prosecuting Pfizer for its fraudulent marketing, the pharmaceutical giant had a trump card: Just as the giant banks on Wall Street were deemed too big to fail, Pfizer was considered too big to nail.

Why? Because any company convicted of a major health care fraud is automatically excluded from Medicare and Medicaid. Convicting Pfizer on Bextra would prevent the company from billing federal health programs for any of its products. It would be a corporate death sentence.

Prosecutors said that excluding Pfizer would most likely lead to Pfizer's collapse, with collateral consequences: disrupting the flow of Pfizer products to Medicare and Medicaid recipients, causing the loss of jobs including those of Pfizer employees who were not involved in the fraud, and causing significant losses for Pfizer shareholders.

Public records show that the subsidiary was incorporated in Delaware on March 27, 2007, the same day Pfizer lawyers and federal prosecutors agreed that the company would plead guilty in a kickback case against a company Pfizer had acquired a few years earlier.

As a result, Pharmacia & Upjohn Co. Inc., the subsidiary, was excluded from Medicare without ever having sold so much as a single pill. And Pfizer was free to sell its products to federally funded health programs.

Two years later, with Bextra, the shell company once again pleaded guilty. It was, in effect, Pfizer's imaginary friend stepping up to take the rap.

"It is true that if a company is created to take a criminal plea, but it's just a shell, the impact of an exclusion is minimal or nonexistent," Morris said.

Prosecutors say there was no viable alternative.

"If we prosecute Pfizer, they get excluded," said Mike Loucks, the federal prosecutor who oversaw the investigation. "A lot of the people who work for the company who haven't engaged in criminal activity would get hurt."

Did the punishment fit the crime? Pfizer says yes.

It paid nearly $1.2 billion in a criminal fine for Bextra, the largest fine the federal government has ever collected.

It paid a billion dollars more to settle a batch of civil suits -- although it denied wrongdoing -- on allegations that it illegally promoted 12 other drugs.

To prevent it from happening again, Pfizer has set up what it calls "leading-edge" systems to spot signs of illegal promotion by closely monitoring sales reps and tracking prescription sales.

It's not entirely voluntary. Pfizer had to sign a corporate integrity agreement with the Department of Health and Human Services. For the next five years, it requires Pfizer to disclose future payments to doctors and top executives to sign off personally that the company is obeying the law.

Pfizer says the company has learned its lesson.

But after years of overseeing similar cases against other major drug companies, even Loucks, isn't sure $2 billion in penalties is a deterrent when the profits from illegal promotion can be so large.

"I worry that the money is so great," he said, that dealing with the Department of Justice may be "just of a cost of doing business."

Risk-taking peaks in adolescence, according to scientists at UCL (University College London).

In research published in the journal Cognitive Development, children, adolescents and adults aged 9-35 years chose between risky and safe options in a computer gambling game. Scientists found that the teenagers took the most risks compared with the other groups, with the most risky behaviour seen in 14-year olds.

The results suggest that teenagers are good at weighing up the pros and cons of their decisions (unlike children) but take risks because they enjoy the thrill of a risky situation more than other age groups - especially when they have a 'lucky escape'.

"The reason that teenagers take risks is not a problem with foreseeing the consequences. It was more because they chose to take those risks," said Dr Stephanie Burnett from the UCL Institute of Cognitive Neuroscience, and the lead author.

"This is the first evidence from a lab-based study that adolescents are risk-takers. We are one step forward in determining why teenagers engage in extremely risky behaviours such as drug use and unsafe sex," she added.

The study involved 86 boys and men who were asked to play computer games, during which they made decisions in order to win points. After each game scientists measured the participants' emotional response by recording how satisfied or dissatisfied they were with the outcome.

They found that the onset of the teenage years marked an increase in how much enjoyment resulted from winning in a 'lucky escape' situation. This could help explain why teenagers are more likely to take bigger risks.

"The onset of adolescence marks an explosion in 'risky' activities - from dangerous driving, unsafe sex and experimentation with alcohol, to poor dietary habits and physical inactivity. This contributes to the so-called 'health paradox' of adolescence, whereby a peak in lifetime physical health is paradoxically accompanied by high mortality and morbidity.

"Understanding why adolescents take such risks is important for public health interventions and for families," said Dr Sarah-Jayne Blakemore, also from the UCL Institute for Cognitive Neuroscience, and co-author of the research.

The research was funded by the Wellcome Trust and the Royal Society.

Article: 'Adolescents' heightened risk-seeking in a probabilistic gambling task' published online in the journal Cognitive Development 25 March 2010.

The U.S. Food and Drug Administration (FDA), SNM and the Radiological Society of North America (RSNA) are hosting a joint two-topic workshop, April 13-14, 2010 at the Natcher Conference Center of the National Institutes of Health, Bethesda, Md. The first day of the workshop will focus on general issues of standardization to control variability and inconsistency in methods of acquisition, interpretation and analysis of images in clinical trials. The second day of the workshop consists of an interactive tutorial on ways to address the FDA regulatory expectations for positron emission tomography (PET) drugs, particularly with respect to the recently issued regulations establishing the Current Good Manufacturing Practice (cGMP).

"This workshop offers a unique opportunity to work with the imaging community to help optimize the role of imaging in public health," said Dwaine Rieves, M.D., director of the Division of Medical Imaging Products in the FDA's Center for Drug Evaluation and Research. "This is an example of the FDA's focus on transparency and its collaboration with stakeholders to ensure that regulated products are both safe and effective."

"We are delighted to be partnering with the FDA and RSNA to bring the molecular imaging community together on the important transition to the new regulations," said Michael M. Graham, Ph.D., M.D., president of SNM. "The PET community remains very focused on preparing to comply with these regulations and is committed to working together to ensure a smooth transition."

"We are very pleased to be working with the FDA and SNM - and the wider community - to discuss critical issues central to the use of imaging as an endpoint in clinical trials," said Daniel Sullivan, M.D., RSNA Science Advisor. "Standardization is essential to improving the value and practicality of imaging biomarkers."

The FDA published a final regulation on current good manufacturing practice (CGMP) for the production of PET drugs in December 2009. The new regulations, known as 21 CFR Part 212, take effect on Dec. 12, 2011. All PET drug manufacturers will be required to submit a new or abbreviated drug application for PET drugs in commercial/clinical use by that date. In the interim, U.S. facilities must continue to comply with USP General Chapter <823>, which sets standards for the production of PET drugs.

The clinical symptoms of alcoholic peripheral neuropathy were described more than 200 years ago. The descriptions by Lettsom (1787)1 and Jackson (1822)2 have led to the recognition and association of peripheral nerve disease with excessive ethanol use. Several terms connote alcohol neuropathy, including neuritic beriberi, neuropathic beriberi, and alcoholic neuritis. In patients with alcoholic neuropathy, nutritional deficiency goes hand in hand with alcohol abuse.

The similarity between beriberi, which is caused by deficiency of thiamine (vitamin B 1 ), and alcoholic neuropathy had long been noted, but in 1928, Shattuck was the first to seriously discuss the relationship.3He suggested that polyneuritis of chronic alcoholism was caused chiefly by failure to take or assimilate food containing a sufficient quantity of vitamin B complex and might properly be regarded as true beriberi. However, this theory may be only partially true. Independently of thiamine deficiency, ethanol now appears to have a direct toxic effect on peripheral nerves.

Pathophysiology

The precise pathogenesis of alcohol neuropathy remains unclear. Separating ethanol use from nutritional and vitamin deficiencies, especially thiamine, has always been difficult and a source of long-standing debate. Nutritional deficiency (frequently associated with alcohol neuropathy) and/or the direct toxic effect of alcohol or both have been implicated and studied. In Wernicke-Korsakoff syndrome, a clear association between reduction of thiamine levels or thiamine-mediated enzyme activity (transketolase) has been established, though this has not been conclusively established in the case of peripheral neuropathy.

In their comparison of patient with alcoholism and nonalcoholic control subjects, Behse and Buchthal concluded that nutritional deficiencies alone did not produce the neuropathy.4

Monforte et al concluded that alcohol appears to be toxic to autonomic and peripheral nerves in a dose-dependent manner, based on heart rate, blood pressure, and electrophysiologic examination.5

In a study of macaque monkeys, Hallett et al failed to produce clinical and electrophysiologic signs of neuropathy in monkeys that were given a certain amount of alcohol for 3-5 years.6

Studies in rats also failed to demonstrate a direct toxic effect of alcohol on the peripheral nerves.

Most studies of peripheral neuropathy in humans and animals implicate nutritional deficiency as an etiology as opposed to the direct toxic effect of alcohol.

Independent of thiamine deficiency, ethanol now appears to have a direct toxic effect on the peripheral nerves. Dina et al suggest that catecholamines in nociceptors are metabolized to neurotoxic products by monoamine oxidase-A (MAO-A). This can cause neuronal dysfunction, which leads to neuropathic pain.7

Painful alcoholic polyneuropathy with predominant small-fiber loss and normal thiamine status is well known. The clinicopathologic features of painful symptoms and small axon loss are distinct from those of beriberi neuropathy. This supports the view of direct neurotoxic effect by alcohol or its metabolites.8

Axonal transport and cytoskeletal properties are impaired by ethanol exposure. Protein kinase A and protein kinase C may also play a role in the pathogenesis, especially in association with painful symptoms.9

Frequency

International

Depending on criteria and patient selection, incidence of peripheral neuropathy ranging from 10-50% has been reported. These studies included alcoholics hospitalized for other reasons or for detoxification. Neuropathy is more prevalent in frequent, heavy, and continuous drinkers compared to more episodic drinkers.5

Mortality/Morbidity

Johnson and Robinson studied the mortality rate of individuals with alcoholism who had autonomic neuropathy. 10

Their findings suggested that evidence of vagal neuropathy in long-term alcoholics is associated with a significantly higher mortality rate than in the general population (a reported 88% survival rate at 7 years in alcoholics with autonomic neuropathy as compared to 94% in the general population).

Deaths due to cardiovascular disease are a major factor.

Many deaths were attributed to strokes, since heavy alcohol consumption is a significant risk factor for stroke.

Sex

A high incidence of alcoholic polyneuropathy has been observed in women and men. Women, when compared to men, are more predisposed to alcohol-induced damage, and the susceptibility extends to hepatic, cardiac, cerebral, and muscular changes. Also, there appears to be a greater sensitivity of females to the toxic effects of alcohol on peripheral nerve fibers unrelated to malnutrition.

Clinical

History

Clinical manifestations of alcoholic neuropathy can be summarized as slowly progressive (over months) abnormalities in sensory, motor, autonomic, and gait function. Patients might ignore early symptoms, and seek help only when significant complications develop. Symptoms are often indistinguishable from other forms of sensory motor axonal neuropathy.

Sensory symptoms include early numbness of the soles, followed by dysesthesias of feet and legs, especially at night. "Pins and needles" sensation, which is reported commonly, progresses to severe pain that is described as burning or lancinating. Symptoms typically start distally and progress slowly to proximal involvement (dying-back neuropathy). When symptoms extend above the ankle level, the fingertips often get similarly affected, giving rise to the well-known stocking and glove pattern. Paresthesia might become unpleasant, even painful.

Sympathetic dysfunction is rare but if present can produce orthostatic hypotension and hypothermia.

Frequent falls and accidents are common. These are secondary to gait unsteadiness and ataxia that are caused by cerebellar degeneration, sensory ataxia, or distal weakness.

Physical

Examination shows distal sensory loss in the lower extremities. In severe cases, the hands may be involved.

In addition to distal atrophy and weakness, deep tendon reflexes usually are decreased or absent.

Stasis dermatitis, glossiness, and thinness of skin of the lower legs are common findings.

Hyperesthesia and hyperalgesia may be seen along with hyperpathia.

Excessive sweating of the soles and dorsal aspects of the feet and of the palms and fingers is a common manifestation of alcoholic neuropathy and is indicative of involvement of the peripheral (postganglionic) sympathetic nerve fibers.

Occurrence of trophic ulcers is rare.

Charcot arthropathy, also known as neuroarthropathy, is most commonly associated with diabetes mellitus, despite a variety of other etiologies. It has also been associated with chronic alcoholism in nondiabetic individuals.

Pressure palsies include radial neuropathy (Saturday night palsy), which is radial nerve compression at the spiral groove that yields wrist drop, in addition to compression neuropathy at many additional sites. Ulnar neuropathy at the elbow, radial or axillary nerve injury in the axilla (crutch-type compression), peroneal neuropathy at the fibular head, and superficial radial nerve are just a few of the potential sites of nerve injury.

Causes

Variants

Rare cases of acute or subacute alcoholic peripheral neuropathy have been described. They mimic Guillain-Barré syndrome, although biopsy and electrodiagnostic studies have revealed an axonal neuropathy, with normal CSF parameters. A causal association with ethanol has been proposed.

Pressure palsies: Alcoholics with generalized axonal peripheral neuropathy are prone to pressure palsies at multiple sites. Associated nutritional deficiency and weight loss might potentiate the same. Neurapraxia is more common than axonotmesis, and recovery is often the rule, although elderly patients do poorly.

A disaster occurs somewhere in the world almost daily; however, to most people, disasters of the type discussed in this article are unusual events. A group of disasters, starting with the September 11th terrorist attacks and continuing through the tsunami affecting countries throughout the Indian Ocean, the South Asia earthquake in Pakistan, the 2005 and 2008 Gulf Coast hurricanes, and the 2010 earthquake in Haiti have focused people's attention upon this topic.

Despite the increase in general awareness with recent events, the relative infrequency of major catastrophes affecting defined populations, leads to a certain degree of complacency and underestimation of the impact of such an event. The result of complacency is relative reluctance to devote the necessary resources for adequate disaster preparedness. Indeed, several authors note that the best time to propose major changes for disaster preparedness, including its funding, is immediately following a major disaster, even if the event has occurred in a remote location.

In the United States, large multiple-casualty events are exceptionally rare by world standards. Only 10 disasters in US history have resulted in more than 1000 fatalities (see Table 1). The vast majority of major events have resulted in fewer than 40 fatalities. According to data from the Centers for Disease Control and Prevention, the September 11th attacks caused 2819 deaths. Compared with 44,065 deaths from motor vehicle accidents in 2002, this number is small. However, the dramatic nature of disasters, with a relatively large death toll and psychological impact for a short time period can overwhelm an unprepared health and response system.

*Exact death tolls can be difficult to calculate, and some of these numbers are estimates.**Even in modern times, death tolls can be difficult to establish. Debate still exists about the actual number of people who died during Hurricane Katrina and its aftermath. An article by Brunkard et al published in Disaster Medicine and Public Health Preparedness in August 2008, puts the Louisiana death toll at 971 plus another 15 deaths among evacuees.1An Associated Press article from 2006 claims the total number of bodies recovered from Louisiana and Mississippi was more than 1300.2There is also ongoing investigation into the possibility that the storm caused deaths during subsequent months and years due to myriad causes (eg, inadequate medical care, relocation stresses).

When a disaster strikes, the general population expects public service agencies and other branches of the local, state, or federal government to rapidly mobilize to help the injured and the community in general. Preservation of life and health are of paramount importance to those individuals injured in the disasters. For this reason, medical professionals must be included in all phases of disaster planning, as well as in the immediate response to these events. Adequate preparation has become particularly important following the problematic response seen during Hurricane Katrina.

Classifying Disasters

Natural versus technological disasters

Disasters are classified in a variety of ways. A common system divides incidents into natural and technological (human-made) disasters. For planning purposes, this distinction provides little conceptual help as there are frequent crossovers. For example, artificial structures may collapse as the result of hurricanes or earthquakes. During Hurricane Katrina, emergency personnel had to contend with fires while rescuing people from flooded areas.

Certain generalizations, however, may be made about natural disasters. Tornadoes may be quite lethal but are generally short-lived. Hurricanes cut a wider swath than tornadoes, tend to last longer, and have more long-term recovery effects. Tornadoes, hurricanes, and floods tend to occur in certain geographic locations. Volcanoes also may be quite lethal but have become more predictable in recent years. Until recently, the most devastating natural phenomena, with regard to numbers of fatalities, were thought to be earthquakes. However, the December 2004 tsunami affecting countries throughout the Indian Ocean, with an official death toll of 224,228 people, ranks as one of the most lethal disasters in recorded history.

Technological disasters tend to be more contained but can be quite lethal. Fires have caused some of the largest numbers of casualties in this country. Toxic spills (ie, release of cyanide gas in Bhopal, India) and nuclear mishaps (ie, Chernobyl) have caused short- and long-term havoc, death, and destruction.

War and terrorism

Other incidents with potential for mass casualties and disaster include war and terrorism. Since the 9/11 attacks on the World Trade Center in New York City, terrorism has become a major focus of disaster response and preparedness. Although the world has yet to experience a terrorist-related nuclear disaster, the raw materials and technology exist to develop nuclear devices as small portable units such as "dirty-bombs." No geographical location is immune from the devastating effects of terrorism. These activities have become more frequent and lethal in recent years with no forewarning, as evidenced by the 9/11 attacks, the Madrid and London bombings, and the more distant, but still tragic, Sarin nerve agent attack on the Tokyo subway system.

Classifying disasters

Disasters are often classified by the resultant anticipated necessary response.

A Level I disaster is one in which local emergency response personnel and organizations are able to contain and deal effectively with the disaster and its aftermath.

A Level III disaster is of such a magnitude that local and regional assets are overwhelmed, requiring statewide or federal assistance.

Disaster preparation

Various methods have been developed to assist planners in disaster preparation. One such method is a modification of the Injury Severity Score. It is based on cause and effect, the area involved, the number of casualties, and other parameters. The potential injury creating event (PICE) system is designed to identify common aspects of a disaster and of response capabilities. Such systems are especially valuable tools in planning for disaster mitigation.

The PICE system uses 4 modifiers to describe a particular disaster (see Table 2). The first modifier describes the potential for additional casualties. The second identifies the degree to which local resources are disrupted. The third modifier identifies the geographic boundaries of involvement. The final modifier, crisis staging, indicates the likelihood of needing outside assistance to augment or replace local resources. It is important to note that in the PICE methodology, identical disasters may have differing descriptors depending on the location of the event and the availability of resources.

Table

Definitions and Terminology

Disaster medicine is difficult to conceptualize. It can be broadly defined.

The World Health Organization defines a disaster as a "sudden ecological phenomenon of sufficient magnitude to require external assistance." The American College of Emergency Physicians (ACEP) states that a disaster has occurred "when the destructive effects of natural or man-made forces overwhelm the ability of a given area or community to meet the demand for health care." Other definitions exist, but the common denominator calls for a disruption of such magnitude that the organization, infrastructure, and resources of a community are unable to return to normal operations following the event without outside assistance.

To further clarify the contrast between normal emergencies and disasters, ACEP states, "emergency medical services routinely direct maximal resources to a small number of individuals, while disaster medical services are designed to direct limited resources to the greatest number of individuals."

In contrast to disasters, multiple casualty incidents (MCIs) have as their primary effects morbidity and mortality to individuals, while the community infrastructure remains relatively intact. A passenger train accident with 500 injured or dead occupants is considered an MCI. However, if this morbidity and mortality were the result of the release of chlorine gas from a hazardous material accident, a much higher potential for additional casualties would exist. Normal operations and activities of daily living would be disrupted for a longer period, which would be considered a disaster by most experts.

Phases of Disaster Response

A disaster cycle has 4 phases, and all responses must pass through each: (1) mitigation, (2) planning, (3) response, and (4) recovery. Pitfalls during transitions can occur throughout the phases. Generalized awareness, proper planning, and contingencies may reduce the overall effect of any specific inadequacy in response.

Mitigation

In certain cases, some of the devastating effects of disasters can be reduced before the actual event. For example, evacuations may be orchestrated before hurricanes or floods. Early warning allows residents to seek shelter from tornadoes. Sprinkler systems in businesses and homes can reduce overall risk of total fire destruction.

Planning

Disaster planning is discussed more thoroughly in External and Internal Planning. It cannot be stressed enough, however, that a disaster plan is not synonymous with disaster planning. Many communities have detailed, "paper" plans, which, when tested, are found to be either based on faulty assumptions or to be totally unworkable in the context of the initial response.

Response

A number of events occur during initial response to a disaster. If there is forewarning, certain aspects of the response may take place even before the event. Unfortunately, significant forewarning is rare.

Activation

Notification and initial response

During this phase, organizations involved in disaster response and the potentially affected populations are notified. In the event that the disaster is anticipated, this phase takes place even before the disaster. Many locations in hurricane areas require more than 24 hours for full evacuation.

Organization of command and scene assessment

Once the activation phase has begun, the prearranged command and staff structure (for details, see Incident Command System below) for responding to the disaster should be arranged and initial communications nets established. This is one of the most crucial steps to take once the disaster occurs. Historically, valuable time may be lost during a disaster response while the central system coordinating the response effort is being prepared. During this phase, initial reports leading to overall scene assessment begin to arrive. For static disasters, required response assets may need to be determined. Often, the only initially known fact is that the disaster is an ongoing process. However, even this fact is important in determining whether outside assistance is needed, leading to timely activation of those resources.

Implementation

Search and rescue

Depending on the structure and function of the incident command system (ICS), search and rescue may fall under the direction of fire, emergency medical service (EMS), or police (security) forces. In contained, geographically localized incidents, the search and rescue effort is fairly straightforward. In larger disasters, especially ones that are ongoing or may involve terrorist activities, a cooperative approach is necessary and the very act of search and rescue must be highly organized to ensure adequate and complete coverage of all areas.

Extrication, triage, stabilization, and transport

Extrication has evolved into a fire services function in most of the country. In addition to specialized technical and trench rescue teams, fire services have more experience with building collapse and secondary hazards (eg, floods, fires) than other organizations.

The concept of triage involves providing the most help for as many as possible. A complete description of triage is beyond the scope of this review. Medical personnel are accustomed to providing extensive, definitive care to every patient. When confronted by numerous patients simultaneously in a disaster situation, it is easy to become overwhelmed, even for an experienced disaster worker. Triage must occur at multiple levels, and patients must be reassessed during every step of the process.

Transport must be both organized and orchestrated to equitably distribute victims to capable receiving facilities. During recent civilian disasters and even in Operation Desert Storm, the majority of critically injured individuals were taken to only one or two receiving facilities, which were almost overwhelmed. This occurred at a time when other facilities sat dormant awaiting patients.

Definitive scene management

While scene control and containment may be relatively simple in a local, static disaster, dynamic disasters and those that paralyze response systems may take several days to contain and stabilize. As the length of time of the disaster increases, additional resources must be made available, as rescue crews reach exhaustion, supplies are depleted, and additional hazards develop.

Recovery

The recovery phase is frequently underemphasized in disaster plans, but it is crucial for the affected community. During this phase, some semblance of order is restored, public utilities are reestablished, and infrastructure begins to operate effectively. Scene withdrawal and a return to normal operations usually occur simultaneously. Treatment of the responders is also vitally important during this phase for critical incident stress debriefing and other support services that have evolved for this purpose.

Debriefing

Valuable lessons may be learned during debriefing. It is of utmost importance to obtain as much information as possible from all parties involved in the disaster response effort. Without full disclosure, similar weak responses will impede future efforts.

External and Internal Planning

External planning

Disaster planning should to the extent possible incorporate formal disaster research findings. Disaster plans sometimes rely on faulty assumptions that do not prove true in actual disasters. For example, planners may logically assume that the sickest patients will be transported first during a disaster, when, in reality, this may not happen in many instances.

A disaster plan encompassing both local and regional areas must focus on 3 possible scenarios:

The disaster occurs within the region and is confined and controlled with existing resources.

The disaster occurs in a neighboring region, and regional assets are requested through mutual aid agreements.

The disaster area is the region and requires state or federal assistance for an effective response.

Incident command system

After a series of fires in California in the 1970s, the Fire Suppression Services developed the ICS concept to organize an effective response to major disasters. The ICS structure includes 5 functional units: command, operations, logistics, planning, and finance (see Media file 1). Most disaster plans include similar organizational structures that are often modified depending on normal operations of the various agencies.

In developing a disaster plan, leaders should remember that it is impossible to plan for all contingencies; therefore, plans must be relatively general and expandable. Most disasters that can be contained using local or regional resources have fewer than 100 fatalities and fewer than 500 major casualties. If plans are developed for larger-scale disasters, the plan should focus on the first 48 hours of the disaster until state and federal assistance teams can arrive and to address high initial fatality rates during the first 24 hours.

Rehearsal

All phases of the disaster response must be addressed in a disaster plan. Functional job descriptions and responsibilities of all agencies and organizations involved should be delineated clearly. More importantly, these plans should be exercised and rehearsed. The ideal exercise includes participation by all parties involved. Since these exercises, by their very nature, disrupt normal operations and are costly in personnel and material utilization, disaster agencies frequently conduct a proxy exercise on the "tabletop." This is a simulation of an emergency situation for training and testing plans and procedures that does not involve movement of response resources. Tabletop exercises are good training tools because they allow people in leadership positions to work through major problems without the cost of running vehicles, using staff and volunteer time, or using supplies. They can quickly highlight areas of weakness where additional support may be needed.

Organization

As part of the Federal Response Plan, the National Disaster Medical System was developed in the 1980s by the Department of Defense, the Veteran's Administration, the Federal Emergency Management Agency, and the Department of Health and Human Services. The Federal Response Plan calls for the development and response of up to 12 functional units to assist, but not direct, the disaster response initiative on declaration of a state of emergency by a territory or state government.

Approximately 1000 stateside beds were identified in preparation for Desert Storm, although no simulation exercise was performed, leading to criticism from the Government Accounting Agency. Disaster medical assistance teams (DMATs) are groups composed of volunteer physicians, nurses, EMS personnel, and others who are transported to disaster sites to participate in the triage, stabilization, transport, and treatment of patients. As examples of use of these teams, DMATs responded to the Oklahoma City Federal Building bombing, Hurricane Katrina, and have prestaged at certain critical events, such as the Atlanta Olympic Games.

Internal planning

Hospital disaster planners must take into account the scenarios previously described, including the possibility that the disaster may involve the hospital. For such rare events, aspects of hospital involvement such as mass decontamination, multiple triage and staging areas within the confines of the hospital, recall of critical personnel, and provisioning of adequate supplies and resupply must be anticipated. The Joint Commission (formerly Joint Commission on Accreditation of Hospitals [JCAHO]) requires hospitals to exercise disaster plans periodically and to form disaster committees. These committees should comprise key departments within the hospital, including administration, nursing services, security, communications, laboratory, physician services (including, but not limited to, Emergency Medicine, General Surgery, and Radiology), medical records, and maintenance/engineering.

The hospital disaster plan should include protocols and policies that meet the following needs:

Recognition and notification

Assessment of hospital capabilities

Personnel recall

Establishment of a facility control center

Maintenance of accurate records

Public relations

Equipment resupply

New, more stringent requirements for health care organizations were approved by the Joint Commission in 2000 and went into effect in 2001. Probably most significant are the requirements to integrate hospital disaster planning into community plans, to ensure that disaster programs address all phases of the disaster cycle, and to have the capability to evacuate the entire hospital staff and patients and relocate and operate from an independent facility. Discussions are continuing with the Joint Commission to further strengthen requirements concerning decontamination, polices, and training in response to terrorist activities involving chemical, biological, radiological, nuclear, and explosive agents.

Summary

Disaster planning is a regional effort. Every jurisdiction should plan for MCIs and disasters. All plans must be simple and based on normal daily operations of the various components involved in the disaster plan. Personnel potentially involved must be familiar with the disaster plan. It should be exercised frequently, even if only by tabletop exercises. Contingency plans for mutual assistance and state or federal response also must be considered and reviewed.